Summary: Ms D says the Council’s care provider provided poor home care support for her mother. As a result, she says her mother was admitted to hospital several times. There was fault by the Council, causing Ms D distress and uncertainty. The Council has agreed a remedy.

The complaint

1. Ms D complains the Council’s commissioned Care Provider, Hartley Home Care, provided poor home care support to her mother Ms X. This resulted in Ms X having falls, pressure sores and problems managing her blood sugar. She complains Ms X was admitted to hospital several times due to the Council’s failings. Ms D also says the Care Provider failed to communicate with the family about significant changes in Ms X’s health and did not call an ambulance as soon as it should have done.

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The Ombudsman’s role and powers

2. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended).
3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

5. I have discussed the complaint with Ms D and considered the information she provided. I have made enquiries of the Council and considered the comments and documents it provided. Ms D and the Council had an opportunity to comment. I considered their comments before making a final decision.
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Relevant law and guidance

Fundamental standards

7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) The Ombudsman considers the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
8. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences. Guidance explains there may be times when a person’s needs and preferences cannot be met. If so, providers must explain the impact and explore alternatives.
9. Regulation 12 of the 2014 Regulations says care must be provided in a safe way including assessing risks to the safety of people using the service and doing all that is reasonably practicable to mitigate risks.
10. Regulation 12(i) of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.
11. Regulation 20 of the 2014 Regulations (the duty of candour) requires care providers to be open and transparent when things have gone wrong. As soon as the care provider becomes aware of a safety incident, it must tell the person or their relative; provide reasonable support, advise them of any further enquiries, keep a written record and apologise.

Safeguarding

12. If a council has reasonable cause to suspect abuse of an adult who needs care and support, it must make whatever enquiries it thinks is necessary to decide whether any action should be taken to protect the adult. (Care Act 2014, section 42).

The Council’s Policy

13. The Council’s Care and Wellbeing Complaint policy (2024) states:

“Where the complainant chooses to use the Council’s complaints procedure, the complaint will be considered under this policy, as if the service were directly provided by the Council.”

Background

14. Ms X, who had diabetes and other health conditions was living at home. The Council had arranged a care provider Hartley Home Care to provide support and care.
15. In 2023 the care provider visited Ms X at home twice a day for 30 minutes. The care plan showed this was to assist with personal care, nutrition and hydration. The plan stated the care provider would assist Ms X with a shower twice a week, and would assist her to wash her lower half five days a week as Ms X was able to independently wash her top half.

What happened

16. What follows is a summary of key events and is not intended to cover everything that happened.
17. In March 2003 Ms X went into hospital for 10 days with suspected sepsis. While she was in hospital Ms D said that the Care Provider was not assisting Ms X with a shower and that two carers were needed for this.
18. When Ms X was discharged from hospital the Council carried out a review of the care plan and agreed to add a third visit every day at lunch time to support Ms X with her catheter.
19. The Care Provider considered whether it required two carers to assist Ms X with a shower. A visit from an occupational therapist was arranged. The Council did not make any changes to the plan in relation to showers. However, the Care Provider’s daily care notes show carers regularly asked to support Ms X to have a shower but she refused. Instead, carers carried out a strip wash as Ms X requested.
20. The Care Provider noted on several visits that Ms X had pressure sores and contacted the district nurse when there were problems. There are records showing the district nurse visited Ms X in response.
21. In July Ms X went into hospital again with a suspected infection. She was discharged after approximately three weeks. The care provider noted that Ms X had pressure sores again and contacted the district nurse who visited.
22. In September Ms X was unwell, and when asked she told the carer her blood sugar levels were high. The carer called the Care Provider’s office and it advised the carer to call 111. However, Ms X said that she had already arranged a GP visit the next day. She refused to allow the carer to call 111.
23. The next day Ms X was still unwell, and her blood sugar levels were higher. However, Ms X still refused to call 111. The Care Provider sent a second carer who called the emergency services. Ms X was taken to hospital by ambulance. The Care Provider contacted Ms X’s family to advise it had called an ambulance.
24. In October 2023 while Ms X was still in hospital Ms D complained to the Care Provider that amongst other things:
• Ms X was not receiving showers twice a week due to lack of staff
• Carers were not properly trained in diabetes care and failed to take appropriate action regarding Ms X’s blood sugar levels.
• The Care Provider had not reviewed Ms X’s care. She needed more care visits due to her need to urinate more frequently. As a result, she often had to sit in soiled and wet incontinence pads longer than necessary.
• The Care Provider failed to identify pressure sores.
• The Care Provider did not identify falls risks or act to prevent falls.
• The Care Provider did not inform Ms X’s next of kin of any serious event, such as when Ms X’s blood sugar levels were very high in September.
25. In November 2023 the Care Provider replied to Ms D’s complaint:
• Showers: Its carers visited Ms X in line with its contract. Ms X did not receive a shower twice a week because Ms X’s personal choice was to have a wash rather than a shower.
• Diabetes care: Its carers had training in diabetes care. Ms D chose to monitor her own blood sugar levels, so this was not part of the care plan. The carers had consulted Ms D’s GP in September a few days before she was admitted to hospital. They had called the GP the day before. Carers had suggested Ms D called 111, but she insisted she wanted to see the GP the next day. The Care Provider accepted that in retrospect it made the wrong judgement to accept Ms D's wishes and should have called the family. It said that its care coordinators had met with carers to explain that sometimes they should override the client’s wishes.
• Care reviews: It had reviewed Ms D’s care plans after her discharge from hospital in March, and in June and September 2023. The Council had commissioned the provider to visit three times a day and it had carried this out. It said it had supported Ms D with continence care and personal care. District nurses and the GP had supported Ms D regarding continence, including her request for a catheter to be fitted.
• Pressure sores: Its carers received training to report any risk with pressure sores and then promptly contact the GP or district nurses.
• Falls Risks: the Care Provider said it had identified Ms X had a risk of falling and it had provided support for personal care.
• Communication with family: the Care Provider said the carer had contacted the family about the ambulance call in September when Ms X’s high blood sugar levels were high. But it noted it should have called the family earlier when Ms X refused to call 111.
26. In November 2023 Ms D complained to the Council. She said that the Care Provider’s care and support for Ms X had deteriorated over the last year and this led to three admissions to hospital. She said the doctor admitting Ms X stated it was the worst case of neglect they had ever seen. She provided a copy of the Care Provider’s complaint response. She said it was not Ms X’s wish to have a strip wash rather than a shower and she had not had a shower for years. She asked the Council whether the Local Government and Social Care Ombudsman or the Council was best placed to respond to her complaint.
27. The Council replied that the Ombudsman was best placed to handle the complaint because it was unable to investigate commissioned providers. However, it said it would notify its quality assurance team if Ms D wished. It said this would help shape future actions regarding commissioning the care provider.
28. Ms X passed away a few months later without having left hospital.
29. In response to our enquiries the Council said
• its quality assurance team considered Ms D’s complaint as provider quality feedback rather than a formal complaint. By the end of 2023 the Council considered (HHC) was a low-risk provider and there were no significant concerns.
• the Care Provider had informed the CQC regarding Ms D’s complaint.
• it did not treat Ms D’s report about poor care and neglect as a safeguarding enquiry. It said it had already agreed to review Ms X’s care in early October. On reflection it says it may have been more appropriate to make a safeguarding referral. However, at the point the concern was raised Ms X was in hospital and not receiving care from the provider.

Analysis

30. When Council’s commission care services for a person they remain liable for the service failures of the service provider. So even though Mr X complains about the care agency the Council is liable for the faults of the care agency.

Care provision

31. Provisionally, I consider there was fault by the Care Provider. It accepted that it should have notified the family earlier regarding Ms X refusing to call 111 regarding her blood sugar levels. This fault caused avoidable distress to Ms D. I have recommended a remedy.
32. I consider the Care Provider has taken appropriate steps to prevent the fault occurring again because it has advised carers they should override the clients wishes in these circumstances.
33. I do not consider there was fault by the Care Provider regarding Ms D’s complaints about other aspects of Ms X’s care. The Care Provider’s complaint response is supported by the care notes and its records which show that:
• Ms X refused a shower whenever carers offered to support her to do this. Regulation 9 says a person’s care should be in line with their preferences. Carers could not force Ms X to shower when she asked for a strip wash.
• Ms X monitored her own blood sugar levels. When carers became aware of high levels they took appropriate action. Care was in line with Ms X’s needs and preferences and in line with Regulations 9 and 12(i).
• Carers had provided personal care in relation to maintaining Ms X’s skin integrity and contacted the district nurse about pressure sores when appropriate. This was effective working with the NHS and in line with Regulation 12(i).
• The Care Provider carried out falls risk assessments and noted Ms X’s mobility problems. Care was in line with Regulation 12(i) and reasonably mitigating risks. The Care Provider could not prevent Ms X from falling.

The Council’s response to Ms D’s complaint and safeguarding concern

34. I consider there is fault by the Council because it stated it could not investigate a complaint about commissioned care providers when Ms D complained to the Council. The Council should investigate complaints about care providers in accordance with its Care and Wellbeing Policy.
35. I note that the Council has taken other actions via its quality assurance team and it has referred the matter to the CQC. This has ensured the appropriate oversight regarding the provider.
36. Provisionally, I find there is fault by the Council in not considering the safeguarding concern Ms D raised in November 2023. This referred to neglect by the care provider and so in my view the Council should have considered whether to instigate a section 42 safeguarding enquiry under the Care Act 2014. We cannot say what the outcome of any referral might have been. I note the Council said Ms X was not receiving care from the provider by the time the concern was raised. However, there could potentially have been lessons learnt through a safeguarding investigation that may prevent the same issues reoccurring.

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Agreed action

37. Within one month of my decision, I recommend the Council
• Apologises to Ms D for the avoidable distress and uncertainty caused by the faults I have identified. The Council’s apology should be in line with our guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice.
• Pays Ms D £150 for the distress and uncertainty it caused
38. In addition I recommend that the Council reminds officers
• that they should consider complaints regarding commissioned providers in accordance with the Council’s policy.
• they should make referrals to the safeguarding team for consideration when a person reports neglect by a care provider.
39. The Council should provide us with evidence it has complied with the above actions.

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Final decision

40. There was fault by the Council causing injustice. The Council has agreed a suitable remedy. I have completed my investigation and closed the complaint.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman